Case: Adult sudden onset stutter - neuro or psych

[peaceloveandPA]

35 year old AA healthy female with no prior medical history presents to the ER with sudden onset stutter, short and long term memory loss, chest pain, essential tremors. Past psych history of PTSD (due to physical abuse as a child), placed on abilify and Zoloft 2 weeks ago, but stopped at onset of stutter. ER: chest pain work up negative, CT of head (w/o contrast neg), neg serial neuro exams. Admitted to inpatient psych (where I performed her admission h+p), attending psychiatrist is "stumped" but possible r/o conversion disorder (Placed on cogentin). My exam normal, neg neuro, no deficits, no history of trauma, seizures, etc per patient (husband deployed), no drug use. Pt communicates via sign (now can not utter more than one letter "zzzzzzz....." Or "mmmmmm....". And jaw shakes uncontrollably. Cannot write.

 

Psychiatrist finally ordered an MRI yesterday.... But stated to me she thinks the pt is getting worse. Originally thought PTSD and a recent therapy appt. brought about this conversion d/o, but now not so sure.

 

Any ideas?!

 

 

Let food be thy medicine

[Guest Paula]

Odd presentation of Myasthenia gravis? Does she have any weakness? There is some involvement of the oropharyngeal muscles in MG and limb weakness. Can she eat? Is the cogentin making a difference? Did you do a toxicology screen? I grasping at straws.......

[EMEDPA]

anyone do an eeg for atypical sz?

I agree it sounds psych. we have a pt who ends up in the er sometimes for rx refills who can only say "yup, yup, yup " very loudly unless medicated then his speech is normal.

interesting thing, the MINUTE he gets his meds in his mouth it goes away.....definitely psych.

[jwells78]

You say her neuro is normal, but she cannot write or speak? That doesnt exactly sound non-focal. Obviously with a neg head ct shes going to need an mri/mra to r/o neuro; what about med reaction? Does she respond to any benadryl/ benzos or drug holiday? Were any of her labs abnormal? Esr/crp? I'm grasping too- but sounds like presentation enough to make psych the absolute dx of exclusion...

[MedicinePower]

I would be very interested to find what an EEG reveals. A thorough neurological investigation is important. Broca's area of the brain is responsible for phonation and would be interested in determining if there is a Broca's Aphasia (or Dysphasia) occurring.

 

Here's a trick I learned a long time ago that might be interesting. Have the patient put on noise-cancelling headphones and play some calming music through it, but loud enough that they may not hear their own voice. While the music is playing ask them to read from a piece of paper. Basic sentences will do...doesn't need to be complicated. If they can read without dysphasia then there is a much stronger case for it being psych than neuro.

[skyblu]

Side effect of the antipsychotic? I had a patient on Zyprexa with similar presentation and negative work up, the Zyprexa was discontinued and sxs resolved.

 

Just a thought.

[peaceloveandPA]

She has been off the meds for almost 2 weeks, no improvement. Unchanged with benzos / Benadryl. Neg tox. Not a drug seeker. You are right, neuro is not normal. Ill be interested to see MRI results today.

 

 

Let food be thy medicine

[ventana]

do you have a med list?

 

I would be concerned with a med interaction

 

then ? structural lesion - is low on list, but if never had a head MR maybe worth while.... but highly unlikely given neg noncontast CT

 

EEG is good - sleep deprived one too

 

do you have a hx of vitals?

 

Any lab abnormality at all? Kidney, liver, thyroid.......

 

 

 

 

 

serotonin syndrome was my 1st thought, but I think she's to normal at this time in 2 long off the meds.

Serotonin syndrome symptoms typically occur within several hours of taking a new drug or increasing the dose of a drug you're already taking. Signs and symptoms include:

 

• Agitation or restlessness
  
• Confusion
  
• Rapid heart rate and high blood pressure
  
• Dilated pupils
  
• Loss of muscle coordination or twitching muscles
  
• Heavy sweating
  
• Diarrhea
  
• Headache
  
• Shivering
  
• Goose bumps
  

Severe serotonin syndrome can be life-threatening. Signs and symptoms include:

 

• High fever
  
• Seizures
  
• Irregular heartbeat
  
• Unconsciousness
  

[polarbebe]

Interesting case, thanks for sharing. When was the head CT done? If patient became symptomatic then went to the ER the same day and had a negative head CT that would not be helpful for a small ischemic event. A hypodense region may be visible 24-48 hours after onset of symptoms (prior to that you may sometimes see loss of grey/white border, very subtle compression of ventricles). If head CT was done >48 hours and read negative, I also agree that a structural lesion is less likely given that language is in the anterior circulation and memory is in the posterior circulation; it is possible to have an embolic phenomenon to two vascular territories but no mention of a. Fib (could have been paroxysmal a. Fib that presented with chest pain on that day) or other thrombus/endocarditis.

 

Interested to hear about further results.

[peaceloveandPA]

Ok... Patient is complaining of chest pain. In ER CK of 325, troponin <0.012, Na 147. Renal function, liver function, alk phos, protein, albumin, TSH, urinalysis all normal. Neg hcg, +benzo but given Valium in ER. EKG NSR, borderline t abnormalities in anterior leads. Vitals have been normal this whole time...

 

In July, patient was placed on Zoloft and ambien. Started to have some memory loss, so drugs were stopped. Then placed on abilify. Has been off of abilify for about 2 weeks now.

 

MRI done yesterday negative.

 

Pt now complaining of stumbling, no muscle weakness, no difficulty swallowing but decreased appetite. Still cannot talk, but can write sloppy with left hand. Could not write at all before.

 

Trying to set up a neuro appt. but it's sounding more like psych after getting a better history from husband... (Pt was alone in house with her 1 and 3 year old while he was away)

 

Psychiatrist has placed pt on seroquel, clonopin, prazosin

 

 

 

 

Let food be thy medicine

[peaceloveandPA]

Oh yeah, psychiatrist is not thrilled by my neuro recommendation

 

 

Let food be thy medicine

[jwells78]

What about Guillan-Barre? You said no recent illness... The more I'm reading, the more it sounds like it with Gait/Upper extremity weakness and speech issues. Everything else looks good and I'm assuming she had neg serial enzymes and/or echo/carotid US and stress if you guys chose to go down that path. Interesting case.

[rcdavis]

She has non focal neurological findings... My gut leads to craziness,

 

The other thought, as always should happen with Multiple neurological findings, is a flare of multiple sclerosis.

 

Although the mr was normal ( non contrast though, so may not show amyloid plaques), so the dx needs LP analysis.

 

So, I agree is probably crazy, but MS is serious concern,

Neuro and a speech pathology eval to see exactly which part of speech is being affected.

[peaceloveandPA]

Thank you! I'm afraid I will get chewed out by psychiatry for recommending neuro consult, but honestly we're a small hospital without a lot of good resources and I think she needs better care somewhere else. They just keep increasing her meds because she's more angry ad agitated now. But rightly so because no one can understand her unless u sit with her and let her sign to u. Pretty frustrating on both accounts. Thanks for all ur great advice.

 

 

Let food be thy medicine

[whoRyou]

You sure get some interesting cases. (Celiac and now this)

[peaceloveandPA]

Ha, Medical consulting for a psych hospital.... Interesting, but can't wait til my year is over (2 months).

 

 

Let food be thy medicine

[peaceloveandPA]

UPDATE: after some very high doses of seroquel, this patient suddenly started talking. And it seems that when she got excited, she could string a few words together fine, and then catch herself and mildly stutter again. Now she's on disability and discharged. Looks like conversion disorder was correct.

 

Crazy how the mind works, eh.

 

 

Let food be thy medicine

[cbrsmurf]

Interesting case!

[Derbingle]

Similar to a case we get...one patient with very similar sx except he also drools....dystonic reaction......no more offending agents.....ativan is all pt takes.....facial spasm, jaw shaking, stuttering, squinting eyes in spasm like fashion, sometimes spasm of the upper extrem.....happens repeatedly past 1 yr (2-3 x per week sometimes) Ive only seen pt few-3-4 times.....but pt is in ED a lot being seen by others for same. Worked up extensively in past. Now just gets IM ativan and goes home. (Pt is Addicted to benzos by now im sure).